Routes Of Opioid Administration Research Articles

Blood pressure response to extended-release naltrexone in heroin and prescription opioid users and its implications for cardiovascular morbidity

Background Consuming opioid agonists is a risk factor for cardiovascular disease particularly in intravenous heroin users. The monthly injectable extended-release opioid antagonist, naltrexone (XR-NTX) is an effective treatment for opioid use disorder. The impact of opioid receptor blockade through XR-NTX on blood pressure, a critical risk factor for cardiovascular morbidity, has not yet been characterized. Methods The study evaluated the change in blood pressure during XR-NTX treatment among 14 patients who predominately used intravenous heroin and 24 patients who used prescription oral opioids, all with opioid use disorder. Blood pressure was measured in each patient immediately before the first XR-NTX injection and ∼two weeks after the first injection. The change in diastolic and systolic pressure was compared between the heroin users and the prescription opioids users using analysis of variance. Results XR-NTX treatment was associated with significant decreases in diastolic blood pressure in the heroin group, but not in the prescription opioids group. Systolic blood pressure values in the heroin users showed a decline at trend level only. Conclusions Further research is warranted to replicate our findings and to determine whether XR-NTX effect is relatively specific to blood pressure or generalizes to other components of metabolic syndrome. Distinguishing between heroin and prescription opioid users could shed light on the unique clinical and pharmacological profiles of opioid drugs, particularly regarding their cardiovascular safety. This information can be useful in developing personalized therapeutic strategies based on the route of opioid administration.

Analgesia and Sedation in Critically Ill Patients With Burns.

Analgesia and Sedation in Critically Ill Patients With Burns.

Problematic Opioid Use: A Scoping Literature Review of Profiles.

Background and Objectives:Problematic opioid use can be defined as opioid use behaviors leading to social, medical, or psychological consequences. In some instances, people presenting problematic opioid use can also meet criteria for an opioid use disorder. A growing body of literature highlights different types of people who use opioids, with contrasting characteristics and initiation patterns. In recent years, dynamic trends in opioid use have been documented and studies have demonstrated a shift in profiles.Methods:A scoping literature review was conducted to identify profiles of people presenting problematic opioid use, in order to support the development of tailored interventions and services.Results:Nine articles met the inclusion criteria. Five classifications emerge from the literature reviewed to distinguish types of people presenting problematic opioid use, according to: (1) the type of opioids used, (2) the route of opioid administration, (3) the level of quality of life, (4) patterns of other drugs used, and (5) dependence severity. While samples, concepts, and measurement tools vary between studies, the most salient finding might be the distinct profile of people presenting problematic use of pharmaceutical-type opioids.Discussion and Conclusions:This scoping review highlights that few studies address distinctive profiles of people presenting problematic opioid use. Geographical and chronological differences suggest that local timely assessments may be needed to tailor the service offer to specific needs.Scientific Significance:Future studies should focus on providing a deep understanding of distinct experiential perspectives and service needs, through exploratory quantitative and qualitative designs.

Female rats self-administer heroin by vapor inhalation

Over the last two decades the United States has experienced a significant increase in the medical and non-medical use of opioid drugs, resulting in record numbers of opioid-related overdoses and deaths. There was an initial increase in non-medical use of prescription opioids around 2002, followed later by increased heroin use and then most recently fentanyl. Inhalation is a common route of administration for opioids, with a documented history spanning back to Mediterranean antiquity and up through modern use with e-cigarette devices. Unfortunately, preclinical studies using inhalation as the route of administration remain relatively few. This study was conducted to determine the efficacy of e-cigarette vapor inhalation of heroin in rats. Non-contingent exposure to heroin or methadone vapor produced anti-nociceptive efficacy in male and female rats. Female rats were trained to self-administer heroin vapor; the most-preferring half of the distribution obtained more vapor reinforcers when the concentration of heroin was reduced in the vapor vehicle and when pre-treated with the opioid receptor antagonist naloxone. The anti-nociceptive effect of heroin self-administered by vapor was identical in magnitude to that produced by intravenous self-administration. Finally, anxiety-like behavior increased 24–48 h after last heroin vapor access, consistent with withdrawal signs observed after intravenous self-administration. In sum, these studies show that rewarding and anti-nociceptive effects of heroin are produced in rats by vapor inhalation using e-cigarette technology. Importantly, self-administration models by this route can be deployed to determine health effects of inhaled heroin or other opioids.

Use of Population-Based Surveys for Estimating the Population Size of Persons Who Inject Drugs in the United States.

In the United States, injection is an increasingly common route of administration for opioids and other substances. Estimates of the number of persons who inject drugs (PWID) are needed for monitoring risk-specific infectious disease rates and health services coverage. We reviewed design and instruments for 4 national household surveys, 2012-2016, for their ability to produce unbiased injection drug use (IDU) prevalence estimates. We explored potential analytic adjustments for reducing biases through use of external data on (1) arrest, (2) narcotic overdose mortality, and (3) biomarker-based sensitivity of self-reported illicit drug use. Estimated national past 12 months IDU prevalence ranged from 0.24% to 0.59% across surveys. All surveys excluded unstably housed and incarcerated persons, and estimates were based on <60 respondents reporting IDU behavior in 3 surveys. No surveys asked participants about nonmedical injection of prescription drugs. Analytic adjustments did not appreciably change IDU prevalence estimates due to suboptimal specificity of data points. PWID population size estimates in the United States are based on small numbers and are likely biased by undercoverage of key populations and self-report. Novel methods as discussed in this article may improve our understanding of PWID population size and their health needs.

Non-Opioid Substances Acute Poisonings with Suicidal Intent in Patients with Opioid Use Disorder.

Several epidemiological studies have evaluated the role of illicit drug use in suicide behaviour. To assess patients with opioid use disorder and suicidal intent related to behavior, severity of acute poisoning and the most commonly used non-opioid substances. This cross sectional study included 67 patients diagnosed with opioid use disorder. The study was conducted at the University Clinic of Toxicology in Skopje over a 5-year period (2013-2017). The following variables were examined: gender, age, duration and route of opioid administration, duration of hospitalization, and types of substances used in acute poisoning. Assessment of patients’ behavior and severity of poisoning was made by using the Suicide Behaviours Questionnaire-Revised and the Poison severity score. The majority of patients were male (88.1%). The mean age of patients was 30±6.1 years. The average duration of opioid use disorder was 8.5±3.9. A single poisoning was found in 62.7%, double poisoning in 25.4%, and triple poisoning in 11.9% of participants. Benzodiazepines were most commonly used by the patients (55.2%). The largest number of patients (32.8%) had minor Poison severity score (PSS), and only 17.9% had severe PSS. None of the patients had a fatal suicide attempt. 86.6% of patients had a score of ≥7 indicating a high risk of repeat suicide attempts. Benzodiazepines were most commonly used as a single or combined substance in patients with opioid use disorder. PSS indicated that most of the participants were with minor PSS and with high risk of a repeat suicide attempt.

Opioids for Relief of Dyspnea Immediately Before Death in Patients With Noncancer Disease: A Case Series Study.

Dyspnea is commonly found in most conditions among patients with progressive noncancer disease. To clarify the effectiveness and safety of opioid administration for the treatment of dyspnea immediately before death in patients with noncancer disease. A retrospective case-series study involving 13 consecutive terminally ill patients who were near death and diagnosed with noncancer disease, and had refractory dyspnea and received opioid therapy, was performed. The authors investigated the route of administration, period, dosage of opioids, intensity of dyspnea-scored according to the Japanese version of the Support Team Assessment Schedule-and clinical course from a review of medical records. The mean age of the patients was 86.5 ± 7.6years (range: 72-98years). The primary causes of dyspnea that led to opioid administration were heart failure (n = 10) and respiratory failure (n = 3). Oxycodone was used in one patient who experienced a complication of chronic renal failure; morphine was used in the other 12 patients. The route of opioid administration was continuous infusions in 11 patients, suppository in one, and oral administration in one. The final dose of oral morphine equivalents was 20.1 ± 8.1 mg/d (range: 5-36 mg [median: 18 mg]). All patients improved in symptom score after opioid administration. The score was significantly decreased from 3.2 ± 0.7 at the beginning of opioid administration to 1.2 ± 0.6 at final estimation (P < .001). No severe adverse events occurred. Low-dose opioid administration in patients with terminally ill noncancer improved dyspnea and occurred no severe adverse events.

Do transdermal opioids reduce healthcare use in an Australian rural pain population? A comparison with oral opioids

To determine whether transdermal (TD) opioids reduce healthcare contacts when compared with oral opioids in a rural population with chronic noncancer pain (CNCP). An observational longitudinal study to measure the changes in self-reported healthcare use by the route of opioid administration over time (monthly for 1 year). Subjects were opioid-treated CNCP patients from North West Tasmania. The subjects completed the monthly datasheets by recording all healthcare contacts and the routes of opioid administration. The outcome measures of mean monthly healthcare contacts (MHCs) by the routes of opioid administration were analyzed using generalized estimating equations with robust standard errors. The details of 10,564 healthcare contacts from 198 subjects were obtained during the study. General practitioner (GP) mean MHCs were 2.01 (95% confidence intervals [CI] = 1.58-2.45) for oral opioids and significantly (p = 0.02) lower by 0.38 (95% CI = -0.70 to -0.05) contacts for TD opioids. Pharmacy mean MHCs were 2.44 (95% CI = 1.88-3.00) for oral opioids and unchanged (p = 0.86) by -0.04 (95% CI = -0.44-0.37) for TD opioids. Total mean MHCs with oral opioid use were 5.98 (95% CI = 4.93-7.03). With TD opioid use, this was nonsignificantly lower (p = 0.12) by 0.62 (95% CI = -1.40-0.15) contacts. The use of TD opioid preparations, with their prolonged analgesic effect, may reduce total healthcare activity and significantly reduce GP contact. This may particularly benefit a rural population where there is a relative shortage of doctors.

Can a phone call be more effective than an intrathecal implanted pump?

Pain is one of the most prevalent, burdensome, and feared symptoms among cancer patients. Even when the basic principles for the use of analgesic drugs are adhered to, some patients experience insufficient pain relief or considerable adverse effects from systemic opioids. Opioid switching or even change of the route of opioid administration may improve the opioid response in most cases, and only a small proportion of patients with cancer pain should be candidates for spinal treatment. A spinal treatment is indicated if systemic treatment has failed, either because of inadequate analgesia or because of intolerable side effects [10]. Although the proportion of cancer patients who may benefit from invasive therapies is small, it is still extremely important, given the level of suffering of patients unresponsive to multiple trials of opioids, possibly receiving high doses of opioids unsuccessfully and having consistent adverse effects. However, the real need for spinal analgesia remains unknown, as the size of the group from which patients are selected for spinal analgesia is rarely reported, and spinal opioids are often started before systemic opioid administration is optimized [11]. According to the prevalent and more accepted opinion in the field of cancer pain, indications for the use of spinal opioids should include patients treated by systemic opioids with effective pain relief but with unacceptable side effects, or unsuccessful treatment with sequential strong opioid drug trials despite escalating doses [11]. There is a scarcity of comprehensive guidelines in implanting intrathecal drug delivery systems in the treatment of pain caused by cancer, particularly in the selection of patients. In most studies of spinal therapy in cancer pain management, the selection of patients is often based on general considerations such as “failure of traditional cancer pain management approaches,” so that some patients may possibly receive spinal treatments regardless of a previous aggressive systemic approach including opioid and route switching [11]. We report a case of a patient who had been implanted spinally, unsuccessfully, but could be easily managed with simple measures in a traditional hospice with lowlevel facilities, just providing an expert advice by phone.

Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management.

The aims of this study were to 1) estimate differences in pain management process and patient-reported outcomes, pre- and postimplementation of analgesic protocols for adults with sickle cell disease (SCD), and 2) examine the effects of site and visit frequency on changes in pain scores and time to analgesic. A multicenter, prospective, longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009. All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled. Sites formed a SCD quality improvement (QI) team and implemented standard nurse-initiated emergency department (ED) analgesic protocols; outcomes were compared between study periods defined as pre- and postimplementation of protocols. Medical record review was conducted to measure time to administration of initial analgesic, opioids used, route of opioid administration, the change in pain scores from arrival to discharge (negative numbers reflect a decrease in pain scores), and the number of ED visits per individual patient during the study period at each site. On day 7 after the ED visit, a follow-up phone interview was conducted. Patients were queried about their ED pain management using a scale from 1 to 10 (1 = outstanding, 10 = worst). Descriptive statistics are used to report the results. Ordinary least-squares regression models were constructed to measure the effect of time period, site, and number of visits per patient on change in pain score. During the study period, 342 unique patients (57% female, mean ± SD age = 32 ± 11 years) were enrolled and had a total of 2,934 visits. There was no difference in time to administration of the initial analgesic between study periods. Overall, there was a significant decrease in pain scores from arrival to discharge between the pre- and postintervention study periods: the average difference in arrival to discharge pain scores (cm) was greater during the postimplementation period than during the preintervention period (-4.1 vs. -3.6, t = 2.6, p < 0.01). Site 1 had significant improvement between study periods (mean difference = -0.87, t = 2.63, p < 0.01; F = 14.3, p < 0.01). Patients with few ED visits (one to six annual visits, mean difference = -1.55, t = 2.1, p = 0.04) and those with frequent ED visits (7 to 19 annual visits, mean difference = -1.65, t = 3.52, p < 0.01) had a significant decrease in pain scores compared to patients with very frequent ED visits (>19 visits). There was an overall decrease in the use of morphine sulfate (MS) and increase in the use of hydromorphone (χ(2) = 105.67, p < 0.001) between study periods and a significant increase in the use of oral (PO) and subcutaneous (SC) routes, with a corresponding decrease in the intravenous (IV) route (χ(2) = 13.67, p < 0.001). There were no statistically significant differences in patient-reported satisfaction with the attempt to manage pain in the ED between study periods (p = 0.54). While the use of a learning collaborative and implementation of nurse-initiated analgesic protocols was not associated with improvement in time to administration of the initial analgesic, improvements in the decrease in the arrival to discharge pain score and increased use of hydromorphone and the SC route were noted in adults with SCD in the ED.

Do transdermal opioids affect the personal socioeconomic costs of healthcare access in an Australian rural pain population? A comparison with oral opioids

To determine whether there are differences in the personal socioeconomic costs of healthcare access between transdermal (TD) and oral opioid use in a rural population with chronic noncancer pain (CNCP). An observational longitudinal study, measuring change in the self-reported personal time and expense of healthcare access by route of opioid administration over time (monthly for 1 year). Subjects were opioid treated patients with CNCP from North West Tasmania, Australia. Subjects completed monthly datasheets by recording all personal healthcare access time and expense, together with the route(s) of opioid administration. The outcome measures of mean monthly healthcare time (MHT) and expense (MHE), by route of opioid administration, were analyzed using generalized estimating equations with robust standard errors. The details of 10,564 healthcare contacts from 198 subjects were obtained during the study. Total mean MHT with oral opioids was 3.76 hours (95% confidence interval [CI] = 2.21-5.32) and unchanged (p = 0.59) with TD opioids at 3.48 hours (95% CI = 2.23-4.72). Total mean MHE with oral opioids was AU$ 92.72 (95% CI = 51.21-134.24) and unchanged (p = 0.81) with TD opioids atAU$ 89.12 (95% CI = 54.53-123.71). The personal socioeconomic costs of healthcare access for rural patients with CNCP are similar for TD and oral opioid use. The prolonged analgesic affect of TD opioids may be advantageous for rural population.

Opioid delivery in the treatment of cancer breakthrough pain: A review of routes of administration

Analgesics delivered via the oral route of administration (capsules, tablets, or solutions) are most commonly used to treat cancer breakthrough pain (BTP); however, the effectiveness of oral opioids may be limited by slow gastrointestinal absorption and first-pass metabolic effects. Although the limitations presented by oral opioid delivery are acknowledged and formulations and delivery systems that mirror the temporal characteristics of the majority of cancer BTP episodes are available, short-acting oral opioids are the accepted standard of care. The purpose of this review is to provide an overview of the different routes of opioid administration used in the treatment of cancer BTP and briefly discuss the characteristics of different delivery systems.

Clinical Experience With Strong Opioids in Pain Control of Terminally ill Cancer Patients in Palliative Care Settings in Taiwan

Background Strong opioids have been recommended as the mainstay of therapy for moderate-to-severe pain, which is highly prevalent in terminally ill cancer patients. Purposes The aims of this study were to collect valuable data on the clinical use of strong opioid analgesics in the management of pain in terminally ill cancer patients receiving palliative care in Taiwan and disseminate the knowledge gleaned from these data to guide practical opioid treatment and improve pain control in end-of-life care. Methods This study retrospectively reviewed 150 cancer patients who received palliative care in a Taiwanese medical center between July 2005 and August 2008. Information regarding medications for pain control (opioid type, daily dosage, frequency, and route), adverse events, and pain assessments in the last 2 weeks before death was analyzed. Results In the second-last week of life, 97 (64.6%) patients were prescribed morphine only and 43 (28.7%) of them received two or more different opioids. In the last week, patients tended to prefer morphine to other opioids. The mean (standard deviation) daily morphine dosage was significantly higher in the last week [96.79 mg (110.55 mg)] than in the second-last week [88.08 mg (100.87 mg)]. The mean daily dose differed significantly between the gender and the three age groups (≤50, 51–70, and ≥71 years) in the last week of life but did not show difference in the second-last week of life. Subcutaneous injection (114 of 150, 76%) was the most frequent route of opioid administration. In the second-last week before death, patients with an improvement in their usual breakthrough pain level had taken a significantly higher dose of opioids than those who showed no improvement. Conclusion Overall, through appropriate dose adjustments, strong opioid regimens, and appropriate routes, strong opioids can be administered as extremely effective analgesics in the palliative care of patients with intractable cancer pain.

Randomized trial comparing 3 methods of postoperative analgesia in gynecology patients: patient-controlled intravenous, scheduled intravenous, and scheduled subcutaneous

The objective of the study was to determine whether any of 3 routes of opioid administration (patient-controlled analgesia [PCA], scheduled intermittent intravenous [i.v.], or scheduled intermittent subcutaneous [s.q.]) provides superior pain relief and satisfaction among patients undergoing abdominal gynecologic surgery. Patients were randomized to intravenous hydromorphone by PCA, i.v. hydromorphone via scheduled nurse-administered doses, or s.q. hydromorphone via scheduled nurse-administered doses. Self-reported pain and satisfaction were recorded over 48 hours following arrival at the nursing unit. Linear mixed effects modeling was used to compare outcomes among the groups. Neither pain scores nor satisfaction differed by group. PCA patients had higher total opioid use (P < .0001) and a higher rate of pruritus (P = .04). Given these findings as well as those in previous literature, no specific method of postoperative analgesia appears to be superior.

Methadone for cancer pain: What have we learned from clinical studies?

The analgesic ladder guideline proposed by the World Health Organization has been shown to be effective in controlling cancer pain in about 80 percent of patients, but the remaining 20 percent still experience pain. Several strategies have been used to manage refractory cancer pain and opioid toxicity. Switching opioids, alternative routes of opioid administration, optimizing adjuvants, and invasive procedures are proposed treatments. Extensive medical literature corroborates each one of those treatments. Rotation from one opioid to another is a noninvasive strategy to overcome opioid side effects and refractory pain. Frequently, methadone is used during opioid rotation. However, there is a lack of consensus on how to proceed on rotation from morphine to methadone. In the current era of evidence-based medicine, the medical literature fails to answer some cancer pain-management issues. The purpose of this review is to clarify a process for transitioning from morphine to methadone.

Incidence and Characteristics of Naloxone Use in Postoperative Pain Management: A Critical Examination of Naloxone Use as a Potential Quality Measure

Abstract The administration of naloxone may be an important monitor of the quality and safety of postoperative pain management. However, studies that support the use of naloxone as a quality measure are absent. The purposes of this study are to determine the incidence and factors associated with naloxone administration in the postoperative setting and to critically examine naloxone as a potential quality measure. Participants included all postoperative adult inpatients at an academic hospital who received naloxone and an equal number of matched control patients who did not receive naloxone during the calendar year 2003. Medical record audits were performed to examine patient demographics, relevant medical history, postoperatively administered analgesics and central nervous system depressants, documented sedation and respiratory assessments, reason provided for naloxone administration, and patient outcome. Naloxone was administered to .53% (56/10,511) of all adult inpatient postoperative patients. Patients who received naloxone were significantly older and received more central nervous system depressants than cohorts. No significant differences were found in comorbidities, route of opioid administration, or amount of opioids taken by the two groups. Reversal of excessive opioid-induced sedation was the primary reason provided for naloxone administration. However, 25% of the patients were later determined to have a new diagnosis that contributed to sedation. Examination of naloxone administration proved useful in uncovering deficits in structures and processes of care. However, caution is warranted when using naloxone as a quality measure to avoid the implication that higher use indicates opioid analgesic over-treatment or error.

Palliative Care in a National Cancer Center: Results in 1987 vs. 1993 vs. 2000

In the last few years, palliative care for advanced and terminal cancer patients has undergone considerable evolution. We determined the characteristics of patients admitted to the 4-bed Palliative Care Unit (PCU) of the National Cancer Institute (NCI) of Milan in 1987, 1993 and 2000 to evaluate how our diagnostic and therapeutic approaches have changed over the years. We reviewed the charts of every patient admitted to the PCU in 1987, 1993, and the first ten months of 2000. We recorded demographic data; the primary tumor sites; the main reason for admission; the types of therapies administered (oncologic, analgesic, surgical, neurosurgical analgesic procedures, and supportive therapy); the type and number of cardiological, radiological and endoscopic examinations, as well as specialist consultations; the duration of stay and eventual death on the Unit. There were no significant differences regarding gender, age, primary tumor site and death in hospital of the patients admitted during these years. The time spent in hospital increased over time ( P = 0.006). A significant increase was observed in the percentage of patients admitted for supportive therapy ( P < 0.001) and investigation concerning the stage of the disease ( P < 0.001). There was a significant decrease in admission for invasive analgesic procedures ( P < 0.001), as well as for pain diagnosis and/or uncontrolled pain. Uncontrolled pain remained the most frequent reason for admission. Over the years, during hospitalization, 7% to 12% of the patients underwent radiotherapy,1% to 9% had computerized tomography, and 4% to 8% had palliative surgery. More than 50% of the patients received intravenous hydration; a few patients received hypodermoclysis in 1987. Over time, there was a significant increase in “as needed” administration of nonsteroidal anti-inflammatory drugs and a significant reduction in their regular administration (from 24% in 1987 and 1993 to 3% in 2000) ( P < 0.001). The use of codeine, tramadol and methadone increased ( P < 0.001), whereas the use of oral morphine, buprenorphine and oxycodone decreased in 2000 ( P < 0.001). There was a reduction in the use of antidepressants (no significant constant trend) and a significant increase in the use of anticonvulsants, laxatives and pamidronate ( P < 0.001). Regularly administered hypnotics decreased in 1993 and increased in 2000 ( P < 0.001). Over these years, no significant differences were found in the routes of opioid administration, in route switching and in the mean maximum oral opioid dose (ranging from 108 to 126 mg/day). The percentage of patients undergoing percutaneous cordotomy significantly decreased in 1993 and 2000 ( P < 0.001). Over time, there was an increase in requests for specialist consultations, which was significant for neurological, cardiological and oncological consults ( P < 0.001). Although the characteristics of the patients admitted to the PCU did not change over these years, there have been significant modifications in our therapeutic approaches, above all in the use of supportive therapy, adjuvant drugs, opioids and neurosurgical invasive procedures. Moreover, a major collaborative interaction with other specialists of the NCI took place with the aim to tailor treatment for each single patient.

Evaluation of 'mu' versus 'kappa' receptor agonists for preemptive analgesia

The study included 90 adult male and female patients undergoing elective abdominal surgery under general anesthesia. According to the route of drug administration (either i.v. or epidural), they were divided into two major groups (each contained 45 patients). But according to the type of administered opioid, each major group was subdivided into 3 subgroups. All patients included into the study were randomly classified and blindly injected by one of the unknown drugs. The intravenous groups were classified into: group (1) who received fentanyl 100 μg), group (2) who received nalbuphine (20 mg), and group (3) who received saline (control group). The epidural groups were classified into: group (4) who received saline (control group), group (5) who received nalbuphine (5 mg), and group (6) who received fentanyl (100 μg). The results of the study showed that opioids have significant preemptive effects compared to the control groups, whatever their type (μ or κ agonists), and whatever the route of administrations (i.v. or epidural routes). It was also observed that the μ opioid agonist fentanyl provided a better preemptive effect than the κ agonist nalbuphine. The i.v. routes indeed provided better preemptive effects than the epidural routes, but these effects were statistically slightly significant or not significant. The aims of this study were to assess the preemptive effects of opioids, to evaluate the different roles of μ and κ agonists, and lastly to assess the effect of different routes of opioid administration (i.v. versus epidural) on the preemptive response.

Novel routes of opioid administration

Novel routes of opioid administration

Alternate Routes of Opioid Administration in Palliative Care: Pharmacologic and Clinical Concerns

Pain relief at the end of life is a major factor in allowing patients to attend to personal matters and alleviating suffering. The majority of pain management modalities are pharmacological. Among these, opioids are key to pain relief in the preponderance of patients. Yet, most studies show that health professionals lack the attitudes, skills, and knowledge to employ opioids well. This review addresses the problems that clinicians encounter when faced with the need to use opioids for pain relief in ways not commonly addressed in their training due to complications of the underlying disease. The use of sustained release oral preparations to relieve the need to ingest medication every four hours, novel oral preparations of opioids, and the less commonly used routes of administration are discussed. How clinicians can correlate these issues with the altered pharmacokinetics that can be anticipated are explored.